About 50 percent of Americans older than 50 are at risk for osteoporotic fracture

The American College of Physicians (ACP) recommends in an evidence-based clinical practice guideline published today in Annals of Internal Medicinethat physicians treat women with osteoporosis with bisphosphonates (alendronate, risedronate, or zoledronic acid) or denosumab, a biologic agent.

“Physicians should prescribe generic drugs to treat patients with osteoporosis whenever possible and they should discuss the importance of medication adherence, especially for bisphosphonates,” said Jack Ende, MD, MACP, president, ACP.

The American Academy of Family Physicians has endorsed ACP’s guideline.

Osteoporosis is a systemic skeletal disease characterized by decreasing bone mass and deterioration of bone tissue that leads to an increased risk for bone fragility and fracture, especially in the hip, spine, and wrist. An estimated 54 million men and women in the United States have low bone density or osteoporosis. About 50 percent of Americans older than 50 are at risk for osteoporotic fracture.

ACP’s guideline focuses on the comparative benefits and risks of short- and long-term drug treatments for low bone density or osteoporosis, including prescriptions, calcium, vitamin D, and estrogen.

The evidence suggests that physicians should treat women with osteoporosis with drug therapy for five years. Continuing treatment after the initial five years may be beneficial for some patients and may be appropriate after reassessing the risks and benefits of continuing therapy.

ACP recommends against bone density monitoring during the five-year treatment period because the evidence does not show any benefit for monitoring during treatment. ACP also recommends against using menopausal estrogen therapy or menopausal estrogen plus progestin therapy or raloxifene for the treatment of osteoporosis in women. Estrogen treatment is associated with serious harms such as increased risk for cerebrovascular accidents and venous thromboembolic events that outweigh the potential benefits.

Physicians should make the decision whether to treat osteopenic women 65 years of age or older who are at a high risk for fracture based on a discussion of patient preferences; fracture risk profile; and the benefits, harms, and costs of medications.

The evidence does not support frequent monitoring of women with normal bone density for osteoporosis; the data showed that most women with normal bone density measurements did not progress to osteoporosis within 15 years.

ACP recommends that physicians offer drug treatment with bisphosphonates to reduce the risk for vertebral fracture in men with osteoporosis.

“The evidence specifically for men is sparse,” Dr. Ende said. “However, the data did not suggest that outcomes associated with drug treatment would differ between men and women if based on similar bone mineral density, so treatment for men may be appropriate.”

“Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women” is based on a systematic review of randomized, controlled trials; systematic reviews; large observational studies (for adverse events); and case reports (for rare events). Clinical outcomes evaluated were fractures and adverse events.

ACP’s clinical practice guidelines are developed through a rigorous process based on an extensive review of the highest quality evidence available, including randomized control trials and data from observational studies. ACP also identifies gaps in evidence and direction for future research through its guidelines development process.

ACP’s previous recommendations for treating low bone density and osteoporosis to prevent fractures were published in “Pharmacologic Treatment of Low Bone Density or Osteoporosis to Prevent Fractures” in 2008. ACP’s 2017 guideline presents additional available evidence on treatments, including new medications and biologic agents, to prevent fractures in men and women with low bone density or osteoporosis since publication of the 2008 guideline.

Amir Qaseem et al. Treatment of Low Bone Density or Osteoporosis to Prevent Fractures in Men and Women: A Clinical Practice Guideline Update from the American College of Physicians. Annals of Internal Medicine, 2017 DOI: 10.7326/M15-1361